Nokea
The nurse is caring for a client who is postoperative day 1 after a total knee replacement. Which of the following actions should the nurse prioritize?
- A. Encourage use of the incentive spirometer.
- B. Administer pain medication as needed.
- C. Apply a continuous passive motion (CPM) machine.
- D. Check the surgical dressing for drainage.
Correct Answer: C
Rationale: Applying the CPM machine prevents stiffness and promotes mobility post-knee replacement. Options A, B, and D are secondary.
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A nurse is teaching a client about self-administration of Haldol 15 mg po hs. For which side effect/s must the client seek medical attention?
- A. SOB and fatigue
- B. restlessness and muscle spasms
- C. dry mouth
- D. diarrhea
Correct Answer: B
Rationale: Muscle spasms and restlessness are side effects of Haldol.
During administration of oral medications to an elderly, confused client, the client states, 'These pills look funny. They belong to the lady down the hall.' Which of the following is the BEST response by the nurse?
- A. Your physician has ordered new medications for you. They will help you get well.
- B. Remember yesterday when I brought your medications? They look the same.
- C. I'll explain why you are receiving these medications.
- D. I'll be back after I check your medications again.
Correct Answer: D
Rationale: Rechecking medications ensures safety, addressing the client’s concern about a possible error. Options A, B, and C risk administering incorrect drugs.
Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the parents remark: 'We just don't know how he caught the disease!' The nurse's response is based on an understanding that
- A. AGN is a streptococcal infection that involves the kidney tubules
- B. The disease is easily transmissible in schools and camps
- C. The illness is usually associated with chronic respiratory infections
- D. It is not 'caught' but is a response to a previous B-hemolytic strep infection
Correct Answer: D
Rationale: It is not 'caught' but is a response to a previous B-hemolytic strep infection. AGN is generally accepted as an immune-complex disease in relation to an antecedent streptococcal infection of 4 to 6 weeks prior.
The nurse is aware that the effect of antihypertensive drug therapy may be affected by a 75 year-old client's
- A. poor nutritional status
- B. decreased gastrointestinal motility
- C. increased splanchnic blood flow
- D. altered peripheral resistance
Correct Answer: B
Rationale: Decreased gastrointestinal motility, together with shrinkage of the gastric mucosa and changes in hydrochloric acid levels, will decrease absorption of medications and interfere with their actions.
A 68-year-old client has an order for hydrochlorothiazide (Hydrodiuril) 50 mg qd. The nurse knows that teaching has been successful if the client makes which of the following statements?
- A. I should not operate heavy machinery.
- B. I should drink only five glasses of liquid per day.
- C. This medication will cause my urine to turn orange.
- D. I should eat dried apricots each day.
Correct Answer: D
Rationale: Hydrochlorothiazide causes potassium loss; eating potassium-rich apricots indicates understanding. Options A, B, and C are incorrect.